CVD Flashcards

1
Q

Endocarditis Sx

A

Fever, New Murmur, Janeway lesions (nontender on palms/soles), Osler’s nodes (tender nodules of finger/toe pads), Roth spots (red retinal lesions w. pale centers

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2
Q

Endocarditis Dx

A

Modified Duke Criteria
TEE
positive blood cultures

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3
Q

Endocarditis Tx

A

Empiric tx = vancomycin + ceftriaxone Prosthetic valve = add rifampin & gentamicin

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4
Q

Arrhythmias

A

An abnormality in the timing or pattern of the heartbeat caused by a variety of things
Brady or tachy

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5
Q

Cardiac Tamponade Sx

A

Becks triad: hypotension, JVD, muffled heart sounds

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6
Q

Becks triad

A

Hypotension, JVD, muffled heart sounds

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7
Q

Cardiac tamponade Dx

A

EKG: Sinus tachy, low voltage, electrical alternans
POCUS triad (US): Pericardial fluid, RV diastolic collapse, Dilated IVC

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8
Q

Cardiac Tamponade Tx

A

Pericadiocentesis

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9
Q

Chest Pain

A

Nonspecific, can be caused by a variety of disorders like MI’s, anginas, pneumonia, PE

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10
Q

AFib Dx

A

EKG: No identifiable P waves, varying R-R intervals

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11
Q

AFib Sx

A

Unexplained fatigue, palpitations, fainting, SOB, chest pain, stroke (common from left atrial appendage)

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12
Q

AFib Tx and management

A

Anticoagulation: rivaroxaban, apixaban, dabigatran, edoxaban, warfarin, heparin
Rate control – older, preserved EF, asymptomatic. Rx = BB, CCB
Rhythm control – younger, symptomatic, EF <45%, new onset

Cardioversion or ablation if the above doesnt work

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13
Q

CHA2DS2-VASc

A

Anticoagulation if score is 2+.
1 pt: CHF, HTN, DM, Vascular disease (MI, PAD, atherosclerosis), age 65-74, female
2 pt: age 75+, stroke/TIA

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14
Q

Atrial Flutter dx

A

EKG: Produces a classic “sawtooth” pattern of atrial activity with lack of P waves

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15
Q

Atrial Flutter Tx

A

Anticoagulation

Cardioversion, if hemodynamically unstable

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16
Q

SVT definition

A

Rapid rhythm disturbances originating from the atria or the atrioventricular node (narrow complex)

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17
Q

SVT Sx

A

Abrupt onset, heart racing/palpitations, SOB, diaphoresis, chest pain, rapid breathing, dizziness, loss of consciousness

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18
Q

SVT dx

A

EKG: narrow QRS complex, usually 160-220 bpm, rate does not vary

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19
Q

SVT Tx

A

Physical maneuver if isolated incidences (valvsalva, hold breath, head btw knees, ice water)
IV Adenosine (in acute setting) Only give adenosine if narrow QRS
Send for EP study (stable), cardiovert (if unstable)
Ablation (definitive treatment)

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20
Q

LBBB vs RBBB

A

LBBB= wide QRS (>0.12s), will have –> think batman
RBBB = left ventricle depolarizes first, then right (b/c that’s where delay is) –> think rabbit ears
V1, V2 = RBBB
V5, V6 = LBBB

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21
Q

VTach EKG findings and Sx

A

EKG: Wide QRS (>120ms) originating from ventricles (rate >100)
Sx: May present as syncope +/- hemodynamic stability

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22
Q

VTach Tx (initial vs long term)

A

Initial: Urgent cardioversion, IV amiodarone
Long-term: reverse cause, BB if structural heart disease, ablation, ICD if cardiomyopathy/EF<35% after GDMT

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23
Q

Torsades de pointes causes, EKG findings, and Tx

A

Cause: commonly hypomagnesemia if electrolyte disturbance
Clinical Pearl: Prolonged QT interval = higher risk of developing polymorphic VT
Tx: IV magnesium

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24
Q

VFib EKG findings and tx
What happens to ventricles during VFib?

A

Main cause of sudden cardiac death in pts w. MI
Ventricles quivering w. no forward cardiac output
EKG: Chicken scratch
Tx: ACLS (defibrillation, epinephrine, antiarrhythmics)

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25
PVC definition
Premature, ectopic, wide complexes, compensatory pause
26
PVC Sx
Most asymptomatic, can feel heart skip a beat
27
What are PVC's associated with?
May be associated w. caffeine, energy drinks, stress, electrolyte abnormalities, hyperthyroidism
28
PVC tx (symptomatic vs asymptomatic)
Asymptomatic: None Symptomatic: 1st line is beta-blockers or non-dihydropyridine CCB.
29
PAC definition
An extra heartbeat that occurs occasionally, often for no known reason, momentarily throwing off the heart's normal rhythm
30
STEMI labs
Positive troponin or CK-MB Positive as early as 4-6 hrs after MI onset, abnormal by 8-12 hrs May remain elevated 5-7 days+ CK-MB generally normalizes w/in 24 hrs
31
STEMI EKG
Peaked “hyperacute” T waves ST-segment elevation Q wave development or old infarct T wave inversion New LBBB – considered STEMI equivalent until proven otherwise (reference old EKGs)
32
STEMI Sx
Chest pain Shortness of breath or trouble breathing Nausea, stomach pain or discomfort Heart palpitations Anxiety or a feeling of impending doom. Sweating. Feeling dizzy, lightheaded or fainting.
33
Anterior wall MI: EKG leads and location in heart
Think about septum & left ventricle V2-V4: anterior wall LAD (affects LV = more prone to LV heart failure) Prone ventricular arrythmias/ shock
34
Lateral wall MI: EKG leads and location in heart
I, aVL, V5, V6 Left Circumflex Artery
35
Inferior wall MI: EKG leads and location in heart
Think right ventricle & SA/AV node II,III,aVF Right Coronary Artery Give IV fluids Pre-load dependent = caution w. nitro & morphine
36
Tx of STEMI, NSTEMI and unstable angina
MONA-BAS Morphine – chest discomfort after NTG; watch bp/pulse Oxygen – supplemental Nitroglycerine Aspirin – 162-325 mg loading dose Beta blockers (oral, IV. Watch BP/HR) Antiplatelet (Clopidogrel, prasugrel, ticagrelor) Anticoagulation (Heparin: enoxaparin [lovenox] or unfractionated heparin)  per doctor in ER if troponin is (+) add heparin Statin (Atorvastatin, rosuvastatin) +/- cath
37
Stable Angina definition and sx
Chest wall discomfort precipitated by stress or exertion and relieved by rest or nitrates Sx: pressure, pain, squeezing, tightness, heaviness… Sx’s are EXERTIONAL and RELIEVED WITH REST <20 minutes duration
38
Stable angina labs and imaging
Negative troponin/CK-MB EKG: Resting EKG is often normal. Possible Ischemic changes: ST depression, T wave flattening or inversion Stress test w or w/o imaging (myocardial perfusion scan or stress echo) Cardiac CTA
39
Stable angina Tx
1st line: Beta-blockers – prolongs life (first line therapy) Aspirin 81-325 mg or clopidogrel 75 mg 2nd line: long acting nitrates
40
Unstable anginas/NSTEMI CP typically lasts (GREATER/LESS) than ____ minutes
Greater than 30 minutes
41
What differentiates an NSTEMI vs unstable angina?
Positive troponin in NSTEMI
42
EKG findings in unstable angina/NSTEMI
ST depression
43
What is the criteria for ST elevation on EKG?
ST segment must be elevated greater than 2 mm (aka greater than 2 small boxes)
44
What medication will you give in a STEMI but NOT an NSTEMI?
Fibrinolytic therapy
45
Definition of Prinzmetal’s/Variant Angina + what causes it
Known as coronary vasospasm Angina pain usually at rest (often b/w midnight-early morning) with no change in exercise function More common in women < 50 May be induced by exposure to cold, emotional stress, or vasoconstricting medications Usually involves right coronary artery (RCA)
46
EKG findings in Prinzmetal’s/Variant Angina
ST elevation- gets confused for STEMI
47
How to dx Prinzmetal’s/Variant Angina and how to tx
Dx: EKG and CTA Tx: CCB and/or nitrates
48
Definition of DOE
Difficulty breathing that is elicited with physical activity. Presents in a variety of CVD and pulm disorders
49
Definition of edema
Swelling caused by fluid trapped in your body's tissues Typically seen in LE dt gravity Can be seen dt infection/inflammation
50
Sx of CHF
DOE, SOB, orthopnea, edema, abdominal bloating/distention, cough, decreased appetite
51
Differentiate right vs left sided CHF
Left-sided: Rales/crackles/wheezes Dullness to percussion S3, S4 or gallop Right-sided: Distended neck veins, elevated JVP (>8 cm) Abdominal distention Pedal edema (1-4+) Hepatojugular Reflux Ascites Liver enlargement/tenderness
52
CHF labs and Dx
Labs: BNP, CBC, CMP Dx: Echo, EKG, CXR
53
What CXR findings can be seen in CHF?
A: Alveolar edema (bat wing opacities) B: Blunting of margins, Kerley B lines C: Cardiomegaly D: Dilated upper lobe vessels E: Pleural effusion, Pulmonary edema
54
CHF tx
BASS  SGLT2-I  ARNI/ACE/ARB  Spironolactone (MRA)  BB (metoprolol or carvedilol) Furosemide if wet CHF
55
What are EKG findings in Atrial enlargement/hypertrophy (RAE/LAE)? What lead should you look at?
Look at lead 2 RAE: taller P wave (kinda looks like mountain with small notch) LAE: wider, notched P wave (looks like 2 boobs)
56
Hypertensive urgency vs emergency Goal reduction BP presenting Signs/Sx Tx
Urgency: Goal: reduce BP in hours BP: >180/120 Signs/Sx: +/- HA/CP, NO evidence of end organ damage Tx: outpatient po -- ACTS meds Emergency: Goal: Reduce BP 10-20% in 1 hour BP: >180-220/120 Signs/Sx: Evidence of end organ damage Tx: inpatient IV (labetalol)
56
EKG findings of LVH
Larger S in V1, larger R in V5 (if greater than 35 mm = LVH) Seaman's sign: R waves touch S waves T waves typically inverted
57
EKG findings in RVH
Reverse R wave progression Normally R wave increases V1 --> V6 RVH: Larger R wave and smaller S in V1
58
Cardiogenic hypotension: definition, causes, Sx and Tx
Volume maintained, decreased CO, incr. resp. effort MI, myocarditis, valvular disease, congenital heart disease, cardiomyopathy, arrhythmias Sx: Decrease cardiac output, hypotension, vasoconstriction (incr. SVR) Tx: Oxygen, fluid resuscitation
59
Orthostatic hypotension causes and Sx
Aka postural hypotension Hypotension when standing up after sitting/laying down Can be dt blood loss, vasodilators, diuretics Sx: * Lightheadedness or dizziness upon standing * Blurry vision * Weakness * Fainting (syncope) * Confusion
60
How to manage orthostatic hypotension (medication vs non medication)
Non medical Management: * External compression devices such as waist-high compression stockings * Physical maneuvers such as lunges, calf-raise, squatting, leg crossing * Increase water and fluid intake to about 2-3 liters per day, avoid dehydration * Increase salt in diet 6-10g/day * Raising the head of the bed to 10 degrees at night Medication Management: Goal = incr. blood volume * Midodrine 2.5 to 15mg PO QD to TID * Fludrocortisone 0.1 to 0.2mg daily in AM titrated up to 1mg daily PRN * Pyridostigmine 30 to 60 mg PO TID * Yohimbine 5.4 to 10.8mg PO TID * Octreotide 12.5 to 50 ug subcutaneously BID * Cafergot such as caffeine 100mg and ergotamine 100mg DONT NEED TO KNOW MEDICATIONS (probably)
61
Definition of orthopnea and how to relieve it
o SOB whilst laying down o Relieved by sitting up o Typically seen in CHF, pericarditis, Pericardial effusion/tamponade, pleural effusion o Tx underlying cause
62
Pericardial effusion definition and Sx
Definition: Extra fluid in pericardial space creates pressure on heart chambers Sx: Asymptomatic (depends on size/effect)- incidental finding Constant dull ache, tachycardia, hypotension, JVD, Pulsus paradoxus (blood pressure decreases with inhalation), dysphagia, dyspnea, Becks triad * Muffled heart sounds * Increased JVP * Hypotension Dullness to percussion L lung over angle of scapula (Ewart’s sign)
63
Pericardial effusion Dx (and their findings) and labs
Labs: CBC, CMP, BNP, ANA Dx: EKG: low QRS voltage with sinus tach, electrical alternans CXR: enlarged cardiac silhouette with clear lungs Can do echo to quantify effusion and assess hemodynamic impact
64
PVD/PAD causes, RF, and clinical findings
Systemic atherosclerosis Risk Factors: CAD, HTN, male, dyslipidemia, incr. age. Diabetes, metabolic syndrome, tobacco use Clinical Findings  Intermittent claudication  Cramping pain in the lower extremities  Induced by activity, relieved with rest  Cool skin temperature  Pale skin color  Scant hair distribution  Weak distal pulses  Nonhealing wounds
65
How to dx and manage PAD/PVD
Dx: Ankle Brachial Index (ABI) (an ultrasound) * Normal: 1.0-1.4 * PAD: < 0.90 * Severe disease: < 0.5 ***CT angiography (Gold standard) or MRA*** Management  Antiplatelet Therapy  Clopidogrel  Aspirin  High-intensity Statin Therapy  Risk factor modification
66
Sx of syncope
 Lightheadedness.  Feeling unstable in the upright position.  Warm or cold/clammy.  Sweating.  Palpitations  Nausea, vomiting, or nonspecific abdominal discomfort.  Visual "blurring"
67
Differentiate between vasovagal syncope, carotid sinus hypersensitivity, cardiogenic syncope, and situational syncope. How do you manage/tx?
Vasovagal syncope - “common faint. Caused by stressful, painful, or claustrophobic experience Carotid sinus hypersensitivity: Stimulation of abnormally sensitive carotid body, with subsequent abnormal vagal response. Results in bradycardia and arterial relaxation/dilation Situational syncope: Enhanced vagal tone with resulting hypotension. Coughing, sneezing, micturition, exercise Cardiogenic syncope: Mechanical or arrhythmic basis arising from heart. Brady: Sinus brady, sinus pauses, AV block Tachy: Ventricular tachycardia Mechanical: Aortic stenosis, Pulmonary stenosis, hypertrophic cardiomyopathy, congenital lesions, massive PE Tx:  Trigger avoidance  Increase fluids and salt  Compression stockings  Counterpressure maneuvers – Reduce venous pooling & improve cardiac output or move to supine position  Leg-crossing with simultaneous tensing of leg, abdominal, and buttock muscles (very effective).  Handgrip – maximum grip on a rubber ball or similar object
68
Aortic stenosis: Sx PE Dx Tx
Narrowing of aortic valve Sx: asymptomatic, SAD (syncope, angina, dyspnea), HF result of LV dysfunction PE: Harsh crescendo-decrescendo systolic murmur (heard best@ RUSB) S1 is usually unaffected, as AS progresses S2 diminishes and can eventually disappear Dx: TTE, EKG (can be normal, LVH, left atrial enlargement) Tx: Valve replacement, Lifelong anticoagulation, TAVR
69
Aortic regurgitation causes (acute vs chronic), Sx, PE, Tx
Causes: * Acute: Infective endocarditis, Marfan's syndrome, Aortic dissection*, Acute prosthetic valve dysfunction, Inflammatory disease, Dilated CM * Chronic: bicuspid valve, dilated CM Sx: Asymptomatic, Exertional dyspnea, Fatigue, Atypical chest pain, Eventual LV dilation & failure, Orthopnea/PND PE: Displaced PMI lateral to midclavicular line in 5th intercostal space Diastolic thrill maybe palpable in 2nd left intercostal space * Wide pulse pressure (big difference in SBP and DBP) * Water Hammer Pulse: Collapsing pulse. Rapid swelling & falling arterial pulse. Best on radial/brachial/carotid pulses. * Corrigan Pulse: Similar to water hammer but referring to carotid artery * Hill’s Sign: Popliteal cuff systolic pressure > brachial pressure by more than 60 mmHg while recumbent. Most sensitive for AI. * Muller’s Sign: visible systolic pulsations of the uvula * De Musset’s Sign: Head-bobbing with each heartbeat * Becker’s Sign: Visible pulsations of retinal arteries & pupils * Rosenbach’s Sign: Systolic pulsations of liver * Gerhard’s Sign: Systolic pulsations of spleen Tx: Mild: vasodilators (hydralazine), diuretics, BB, CCB, ACE Severe: Surgery: TAVR, aortic root replacement
70
Mitral regurgitation Sx (acute vs chronic), PE, Dx, Tx
Sx: Acute MR: sudden onset SOB, orthopnea, LE edema, possible cardiogenic shock Chronic MR: asymptomatic for yrs, then exertional dyspnea & intolerance. Fatigue, orthopnea & PND as MR progresses. Palpitations: possible atrial fibrillation as a result of LA dilation PE: High-pitched blowing Holosystolic murmur Heard best at apex (may radiate to axilla) Possible S3 Dx: Echo (regurgitant volume, EF, LA/LV size, PA pressure, RV function) BNP (early identifier of LV dysfunction) CXR (acute vs. chronic MR) Tx: Meds: o Vasodilators: hydralazine, ACE o Diuretics o Anticoag if Afib Surgery * Acute severe MR (urgent): stabilize w. vasodilators to incr. pulm. Pressure & maximize forward flow * Chronic severe MR (elective): if reduced EF or LV dilation w. reduced contractility
71
Abdominal Aortic Aneurism who to screen
90% originate below renal arteries Involvement of the aortic bifurcation Screening: o Abdominal ultrasound o Men 65-75 years-old o Family history (1st degree relative) o Smoking history (current or past)
72
Abdominal Aortic Aneurism clinical findings (asymptomatic vs symptomatic)
Asymptomatic: Incidental finding on abdominal ultrasound or CT imaging Symptomatic: Sign of rapid expansion or impending rupture  Mild to severe deep abdominal or flank pain that is constant or intermittent  Exacerbated upon palpation  Pain radiates to back
73
Risk of AAA rupture increases drastically when diameter is > _____
Risk of AAA rupture increases drastically when diameter is > 5.5 cm
74
AAA initial screening vs assessing diameter
initial: US assessing: Abdominal CT w. contrast to assess diameter & for surgical planning
75
When to refer for surgical repair for AAA
o Diameter > 5.5 cm o Rapid diameter expansion (> 0.5 cm in 6 months) o Symptomatic – Pain, tenderness
76
What are clinical findings of a TAA
Symptoms dependent upon size & position of aneurysm & rate of growth  Esophagus: dysphagia  Trachea: stridor, dyspnea  Superior vena cava: Upper extremity edema, JVD  Aortic root: Aortic regurgitation  Substernal chest pain  Pain radiating to the back or neck
77
What imaging is used to determine a TAA
Chest radiographs: useful initial evaluation, not sensitive or specific CT Angiography: Best initial imaging for patients suspected to have TAA TEE or TTE
78
Surgical indications for TAA
Diameter > 5.5 cm All symptomatic TAAs require surgical repair
79
An aortic dissection occurs when there is a spontaneous tear of the ____ _____
Spontaneous tear of tunica intima
80
What is the number one cause of aortic dissection?
HTN
81
Clinical findings of aortic dissection
* Sudden onset severe, persistent chest pain described as ripping, sharp, tearing * Pain radiates in respect to location & extent down the back, anterior chest and/or neck * Hypertension * Syncopal episodes * Diminished peripheral pulses * Variations in pulses and blood pressure when comparing extremities
82
Aortic dissection imaging
EKG Chest Radiograph (x-ray): Widening of mediastinum/aortic silhouette CT of chest & abdomen: Immediate diagnostic imaging of choice TEE
83
Aortic dissection tx and management
Surgical Repair Management and Disposition * Aggressive blood pressure control o Reduce to 100-120 mmHg systolic * Beta blockers are the first-line management o Labetalol * Nitroprusside
84
Differentiate between thrombus and embolus
Thrombus * Blood clot results from ruptured atherosclerotic plaque or stagnant blood flow from cardiac arrhythmia * Occlusion of small, distal arteries * History of peripheral artery disease Embolus * A blood clot arising from the vascular system that travels to a distal area, causing occlusion * Occlusion of larger arteries * History of cardiac event
85
Clinical findings of arterial occulsion
Abrupt onset pain in extremity The 5 P’s o Pain o Pulselessness o Pallor o Paralysis o Paresthesia o Limb is cool to touch o Degree of ischemia is related to collateral blood flow
86
Arterial occlusion dx and tx
Dx – typically done off physical Exam Findings & Arterial/Venous Doppler Findings Diagnostics: * Vascular Sonography * Arterial Doppler Ultrasound * CT Angiography * Delayed intervention Tx * Anticoagulation * Unfractionated Heparin IV * Catheter-directed thrombolysis * tPA (Tissue plasminogen activator) * Thromboembolectomy * Revascularization must take place within 3 hours
87
Thrombophlebitis: RF, presentation, PE, Dx, Tx
Risk Factors: virchows triad (venous stasis, vascular injury, hyper coagulability) Presentation: o Dull pain o Erythema o Tenderness o Palpable induration or cord o Most common presentation on PANCE questions will be patient post trauma, or at IV/PICC site Physical exam: erythema, tenderness, cord Dx: Ultrasound: r/o deep vein involvement or occlusion Treatment o Rest o Warm compresses, heat o Elevation o NSAIDS